Health Sciences Division Physical Therapist Assistant Program. Dear PTA applicant:

Health Sciences Division Physical Therapist Assistant Program Dear PTA applicant: Thank you for your interest in the PTA program. Physical therapy is a rewarding and demanding career field with job possibilities in all types of health care environments. Graduates from our program earn a two year Associate in Science Degree and may apply for licensure as a Physical Therapist Assistant by examination in the state of Florida. The PTA program is exciting, challenging and action-packed. The faculty and staff work hard to ensure that the program meets both our community needs and CAPTE accreditation standards. We look forward to helping you by answering any questions you may have about our program or the physical therapy profession. Sincerely, Melinda Cumbaa, PT, MS, DPT Program Coordinator, PTA Program mcumbaa@gulfcoast.edu & Kelli Walsingham, PTA, BSSFM, MS Assistant Coordinator, PTA Program kwalsingham@gulfcoast.edu

PHYSICAL THERAPIST ASSISTANT PROGRAM GULF COAST STATE COLLEGE APPLICATION INFORMATION DEADLINE: MAY 9, The physical therapist assistant (PTA) is a skilled technical health care worker who delivers physical therapy services under the direction and supervision of the physical therapist (PT). PTAs carry out treatments designed by the PT that include a variety of interventions to help patients return to function and activities of daily living. PTA duties may include instructing patients in therapeutic exercises for strengthening, flexibility, balance and coordination; developing mobility and functional skills; applying physical agents such as heat, cold, electricity and traction; and communicating with the PT as the patient s medical condition changes. The physical therapist assistant is responsible for monitoring and reporting the patient's response to treatment to the physical therapist. This requires the PTA to collect data, document treatments administered, and communicate findings objectively. Physical therapy is a rewarding and demanding career field with job possibilities in all types of health care environments. Employment opportunities can be found in a variety of settings including hospitals, rehabilitation centers, nursing homes, home health agencies, schools, and outpatient PT clinics. Salaries generally start anywhere from $34,000 - $42,000 throughout the country, but may be higher or lower in some areas. To be successful in this career you should be comfortable with performing physical activity, have a strong background in science, be able to communicate well with a variety of people and cultures, and have an interest in disease prevention and wellness. The Gulf Coast State College Physical Therapist Assistant Program is accredited by the Commission on Accreditation of Physical Therapy Education and accepts one class of 16-20 students per year in the fall semester. Applications will be accepted any time throughout the year, but the application deadline is MAY 9th for Fall desired admission. It is the student s responsibility to see that the application is complete. The items listed on the front of the Applicant Checklist should be turned into Admissions, and the items on the back of the Applicant Checklist should be submitted with the Health Sciences PTA Application. (You do not need to turn in the Applicant Checklist itself; this document just serves as a guide to help you gather documents in support of your application to the program.) Submit the Health Sciences PTA Application and supporting documents to Room 200, on the second floor of the Health Sciences Building. The program uses a selective admission process, and satisfaction of the minimum requirements does not automatically guarantee admission. Completed applications will be sent to the PTA Admissions Committee for review. All applicants will be notified in writing, within 6 weeks after the deadline, whether they are accepted into the program, placed on an alternate list, or not accepted for the current year. No acceptance results will be given out over the phone. Thank you again for your interest in the Physical Therapist Assistant Program. If you have any questions, please contact: Dr. Melinda Cumbaa at (850) 913-3312 or 1-800-311-3685, ext. 3312 Mrs. Kelli Walsingham at (850) 769-1551, Ext. 6180 or 1-800-311-3685, ext. 6180 Mr. Craig Wise at (850) 913-3311 or 1-800-311-3685, ext. 3311 Mrs. Melissa Bois at (850) 873-3542, or 1-800-311-3685, ext. 3542

GULF COAST STATE COLLEGE PTA PROGRAM ADMISSIONS PROCESS GUIDE Applicant Checklist Submit the items on this list to GCSC Admissions and Records Office: Apply for general admission to Gulf Coast State College and pay application fee at time of submission (Returning students who have not taken classes at GCSC in the last year must re-apply for admission.) Failure to pay the college application fee at the time of submission can result in your ineligibility for program consideration, due to delays with processing. Call (850) 872-3892 locally or toll-free at 1-800-311-3685, Ext. 3892 or visit the college Office of Admissions and Records located in the Administration Annex to receive information regarding the college admissions process. Applications are available online at: http://www.gulfcoast.edu Provide official High School (or GED) AND All College Transcripts to GCSC Admissions & Records Office An official transcript is a transcript that is sent directly from the granting school/institution to the Gulf Coast State College Admissions and Records Office. Transcripts that have been in the student s possession (regardless of whether they are sealed, stamped or in a sealed envelope) are not considered official and will not be accepted. Transcripts must be submitted from BOTH High School (GED) and ALL Colleges or Universities attended and must display all periods of enrollment. The applicant is responsible for ensuring that all college transcripts are evaluated by the May 9th deadline. Demonstrate Math/Algebra, English and Reading Competency Students may demonstrate this competency in one of the following quantitative methods: Subject PERT ACT SAT College Course Application Deadline: May 9, Math/Algebra 114 19 440 English 103 17 440 in Critical Reading 106 19 Reading Successful completion of 3-credit minimum course with prefix MAC, MGF, or STA ENC 1101 English Composition I If the applicant wishes to use test scores to demonstrate competency for any of the above, and the test was not administered at Gulf Coast State College, the applicant must have an OFFICIAL score report sent to the GCSC testing office. The applicant is responsible for ensuring that the test scores are received and posted to their GCSC computer record by the May 9 th deadline. If you are exempt from testing (Flexible Placement), you may elect to take the PERT and enhance your points for admission. The PERT is administered in Student Union West, 3 rd floor testing area, and may be taken two times per semester. The cost is $5.00 per testing session. Please consult the Placement Testing Schedule at http://www.gulfcoast.edu/students/testing_center/cpt.htm or call (850) 769-1551, Ext. 3533 for additional information. Checklist continued on back of this sheet

Submit the items on this list to Division of Health Sciences (Room 200): PTA Program Application Packet Complete the following materials in this packet: PTA Application (Note: This must be submitted early in order for a Bachelor s degree evaluation to be processed.) Technical Standards Form EXTRA CREDIT Completion of these general education courses with a minimum grade of C will earn extra credit for application into the PTA program BSC 2085 Anatomy and Physiology I (Lab is required, but lab grade does not contribute to admission points.) BSC 2086 Anatomy and Physiology II (Lab is required, but lab grade does not contribute to admission points.) HSC 1531 Medical Terminology (Only grade of A or B will earn extra credit for this course.) If these courses are coming from another institution, the applicant is responsible for ensuring that they have been submitted via an official transcript, evaluated and posted to their GCSC computer record by the May 9th deadline. Courses taken at GCSC during the spring semester in which the application has been submitted will also be considered for extra credit. Multiple attempts at a course will result in a reduction of admission points in this section. Work/Observation Form EXTRA CREDIT-Use Provided Form Only Documented evidence of a minimum of 40 hours of work and/or observation in a PT environment; include specific observation and signature of a PT or PTA; additional points will be considered for observation hours documented above the minimum, and hours spent in a variety of settings. At least 10 hours are required for an additional setting to be counted and must indicate Inpatient or Outpatient setting on form. It is required that the applicant use the Physical Therapy Experience Form in this packet; we no longer accept other PT experience forms. NOTE: This is optional but important! [It is the student s responsibility to maintain copies of all application materials, including work/observation hours. We DO NOT carry over, copy, or return applications or other documents.] Additional documentation (if applicable) EXTRA CREDIT: Any advanced degrees and/or current certifications achieved (i.e. BS, BA, MA or MS) in a related field (i.e., exercise physiology, *massage therapy, *athletic trainer certification) (If achieved, must be included in official transcripts sent to GCSC Admissions and Records Office.) A Bachelor's evaluation packet must be completed by the May 9th deadline. (Note: Must send in PTA Program Application in order to have the packet evaluated. Volunteer hours may be updated at any point through May 9 th.) *Must submit a copy of license or certificate with application by the May 9th deadline. Only applications that are current and complete are considered for selection. It is the applicant s responsibility to make sure his/her application folder is complete by the deadline. Please contact us if you have any further questions: Melinda Cumbaa, PT, MS, DPT Kelli Walsingham, PTA, BSSFM, MS Coordinator, PTA Program Assistant Coordinator, PTA Program Gulf Coast State College Gulf Coast State College mcumbaa@gulfcoast.edu kwalsingham@gulfcoast.edu Office: (850) 913-3312 Office: (850) 769-1551, Ext. 6180 Toll-free: 1-800-311-3685, Ext. 3312 Toll free: 1-800-311-3685, Ext. 6180 Mr. Craig Wise Assistant Coordinator, Health Sciences Admissions Gulf Coast State College cwise@gulfcoast.edu Office: (850) 913-3311 Toll-free: 1-800-311-3685, Ext. 3311

GULF COAST STATE COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM CURRICULUM GENERAL EDUCATION COURSES Hrs. Cr. ENC 1101 English I... 3 *College Level Math... 3 BSC 2085 Anatomy & Physiology I... 3 BSC 2085L Anatomy/Physiology I Lab... 1 Humanities Elective... 3 Hrs. Cr. BSC 2086 Anatomy & Physiology II... 3 BSC 2086L Anatomy/Physiology II Lab... 1 PSY 2012 General Psychology... 3 HSC 1531 Medical Terminology... 2 NOTE: General education courses may be taken during the PTA Program; however, applicants are strongly encouraged to begin work on the general education courses prior to entry into the program. Completion of A & P I prior to starting the PTA program is suggested but not required. Extra points will be awarded for a "C" or better in A & P I, A&P II and a B or better in Medical Terminology if completed prior to the application deadline. *The College Level Math Requirement may be satisfied with MAC 1105, MGF 1106, MGF 1107 OR STA 2023 or a higher level math course. COMPLETE PROGRAM: FRESHMAN FALL CREDIT HOURS BSC 2085 Anatomy and Physiology I 3 BSC 2085L Anatomy and Physiology I Lab 1 College Level Math (MAC 1105, MGF 1106, MGF 1107, STA 2023, or higher) 3 HSC 1531 Medical Terminology 2 PHT 1000 Introduction to Physical Therapy 2 PHT 1102 Applied Anatomy for PTA s 2 PHT 1200 Basic Skills in Patient Care 2 PHT 1200L Basic Skills in Patient Care Lab 2 17 SPRING BSC 2086 Anatomy and Physiology II 3 BSC 2086L Anatomy and Physiology II Lab 1 PHT 1124 Functional Human Motion 2 PHT 1124L Functional Human Motion Lab 2 PHT 1220 Introduction to Therapeutic Exercise 3 PHT 1220L Therapeutic Exercise Lab 2 PHT 1131 Assessment, Measurement and Documentation 1 PHT 1131L Assessment, Measurement and Documentation Lab 2 16 SUMMER ENC 1101 English Composition I 3 PSY 2012 General Psychology 3 PHT 2224 Therapeutic Interventions I: Medical/Surgical Disabilities 2 PHT 2224L Therapeutic Interventions I Lab 1 Humanities Elective (Level I, II, OR III) 3 PHT 2211 Therapeutic Modalities 2 PHT 2211L Therapeutic Modalities Lab _2 16

SOPHOMORE FALL CREDIT HOURS PHT 2225 Therapeutic Interventions II: Orthopedic Disabilities 3 PHT 2225L Therapeutic Interventions II Lab 2 PHT 2226 Therapeutic Interventions III: Neurological Disabilities 3 PHT 2226L Therapeutic Interventions III Lab 2 PHT 2801 PTA Clinical Practice I 3 13 SPRING PHT 2810 PTA Clinical Practice II 5 PHT 2820 PTA Clinical Practice III 5 PHT 2931 Seminar _2 12 TOTAL PROGRAM HOURS 74 Typical Physical Therapist Assistant Schedule (Following Curriculum as Designed) On Campus Hours Per Week Off Campus Hours Per Week Semester Class Hours Lab Hours Clinical Prep. Clinical Hours Total Fall 1 14 6 20 Spring 1 9 14 23 Summer 2 20 5 25 Summer 3 12.5 10 22.5 Fall 2 8.25 (for 11 weeks) Spring 2 15 (for 2 weeks) 11 (for 11 weeks) 4 40 (for 4 weeks) 4 40 (for 14 weeks) 19.25 for 11 weeks 40 for 4 weeks 44 The PTA Program is designed as a full-time course of study and students are required to complete courses in the designated sequence. Most classes are offered during daytime hours with only a few evening courses.

Criminal Background Checks Gulf Coast State College (GCSC) students that are granted conditional acceptance into a Health Sciences program must receive a satisfactory criminal background check prior to final acceptance into the program. The background check will be scheduled and performed at the discretion of the Division of Health Sciences at GCSC. Information and instructions on how to complete the background check will be sent by the program coordinator. Criminal background checks performed through other agencies will not be accepted. The student must also be aware that clinical agencies may require an additional background check prior to clinical access. It is possible to graduate from a program at GCSC and be denied the opportunity for licensure because of an unfavorable background check. An applicant must consider how his/her personal history may affect the ability to meet clinical requirements, sit for various licensure exams, and ultimately gain employment. Most healthcare boards in the State of Florida make decisions about licensure on an individual basis. You may visit the Florida Department of Health website (www.doh.state.fl.us/) for more information regarding licensure. We offer this information so that you can make an informed decision regarding your future. Please read the following information carefully: Any student who has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to, any offense under the provision of 456.0635 (see below) may be disqualified from admission to any Health Sciences program. In addition to these specific convictions, there are other crimes which may disqualify applicants from entering into the Health Sciences programs and/or clinical rotations. The statute listed below can also be found online: http://www.leg.state.fl.us/statutes/index.cfm?app_mode=display_statute&search_string=&url=0400-0499/0456/sections/0456.0635.html 456.0635 Health care fraud; disqualification for license, certificate, or registration. (1) Health care fraud in the practice of a health care profession is prohibited. (2) Each board within the jurisdiction of the department, or the department if there is no board, shall refuse to admit a candidate to any examination and refuse to issue a license, certificate, or registration to any applicant if the candidate or applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant: (a) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, or chapter 893, or a similar felony offense committed in another state or jurisdiction, unless the candidate or applicant has successfully completed a drug court program for that felony and provides proof that the plea has been withdrawn or the charges have been dismissed. Any such conviction or plea shall exclude the applicant or candidate from licensure, examination, certification, or registration unless the sentence and any subsequent period of probation for such conviction or plea ended: 1. For felonies of the first or second degree, more than 15 years before the date of application. 2. For felonies of the third degree, more than 10 years before the date of application, except for felonies of the third degree under s. 893.13(6)(a). 3. For felonies of the third degree under s. 893.13(6)(a), more than 5 years before the date of application; (b) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any subsequent period of probation for such conviction or plea ended more than 15 years before the date of the application; (c) Has been terminated for cause from the Florida Medicaid program pursuant to s. 409.913, unless the candidate or applicant has been in good standing with the Florida Medicaid program for the most recent 5 years; (d) Has been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program, unless the candidate or applicant has been in good standing with a state Medicaid program for the most recent 5 years and the termination occurred at least 20 years before the date of the application; or (e) Is currently listed on the United States Department of Health and Human Services Office of Inspector General s List of Excluded Individuals and Entities.

ADMISSIONS PROCEDURE PHYSICAL THERAPIST ASSISTANT PROGRAM 1. Initial Advising and Application Distribution of applications will be handled through the Health Sciences Administrative Office (room 200, Health Sciences building). Applicants assume all responsibility for completion of application materials. Incomplete applications will not be considered in the student selection process. Mr. Craig Wise, Assistant Coordinator-Health Sciences Admissions (850) 913-3311, will be the initial contact person for applicants to the Physical Therapist Assistant Program. Melinda Cumbaa at (850) 913-3312 or Kelli Walsingham at (850) 769-1551, Ext. 6180 can answer questions related to the physical therapy profession. 2. Admissions Committee Each member of the Admissions Committee will review and rate each application independently, assigning points according to the standards, on each admission criterion. Points will be totaled to obtain an overall score for the application. The applicants will be ranked from highest to lowest. When all members of the committee have individually completed review of the applications, the committee will meet as a group to select the class and alternates. The admissions committee adheres to Gulf Coast State College's policies for non-discrimination in student selection. Should there be a tie with the scoring; the admissions committee will use a majority committee vote as the deciding factor in final student selection. Procedures for compliance with non-discrimination policies and procedures guaranteeing students due process may be found in the GCSC Student Handbook. The top 16-20 students will be offered a conditional admission to the program pending satisfactory background check, drug screen and physical examination. Should a health problem or disability be identified which appears to make compliance with the technical standards impossible, the applicant will be requested to meet with the admissions committee and a representative from disabled student services to discuss a possible way of adapting the program to enhance the applicant's chances of succeeding in the required course and clinical work. (See policies re: Disabled Student Services in the GCSC Student Handbook or in the GCSC General Catalog). If it appears the applicant will probably not succeed in the program, final acceptance will be withdrawn. The next 8-10 applicants (by ranked score) will be placed, in order, on an alternate acceptance list for the current program year only, and will be offered admission should a vacancy become available prior to the first day of required class attendance. No waiting list is maintained for subsequent year s enrollment and it is the student s responsibility to maintain copies of all application materials for reapplication in the following year. 3. All applicants to the PTA program will be notified in writing whether or not they are accepted into the current class. PLEASE BE SURE THAT THE ADDRESS ON THIS APPLICATION FORM IS THE MAILING ADDRESS TO WHICH YOU WISH US TO MAIL YOUR NOTIFICATION LETTER. If your mailing address changes after you have submitted this application, PLEASE be sure to notify Craig Wise, 850.913.3311 or the PTA Administrative Assistant, Melissa Bois, 850.873.3542, of this change as well as the Office of Admissions and Records. Accepted students will be provided with a form in June, which must be signed and returned to the PTA program coordinator by the specified deadline, to confirm acceptance of a space in the PTA class.

Physical Therapist Assistant Program Estimated Student Expenses (Based on 2014-2015 fees) Registration will not be officially completed until all fees are paid in full by the dates identified in the college calendar. Students are responsible for all fees for courses not dropped by the student during the refund period. The Physical Therapist Assistant Program requires 74 credit hours of instruction. *In-State Estimate Matriculation fee, per credit hour... 72.92 Student Activity fee, per credit hour... 7.29 Capital Improvement fee, per credit hour... 7.29 Financial aid fee, per credit hour... 3.65 Technology Fee... 3.65 TOTAL, PER CREDIT HOUR... $94.80 Access Fee... 3.95 TOTAL, PER CREDIT HOUR... $98.75 74 credits x 98.75 =... $7,307.50 *Out-of-State Estimate Matriculation fee, per credit hour... 72.92 Tuition, per credit hour... 221.42 Student Activity fee, per credit hour... 7.29 Capital Improvement fee, per credit hour... 24.69 Financial aid fee, per credit hour... 14.72 Technology Fee... 14.72 TOTAL, PER CREDIT HOUR... $355.76 Access Fee... 3.95 TOTAL, PER CREDIT HOUR... $359.71 74 credits x 359.71 =...$26,618.54 Lab fees [includes liability/accident insurance] (approximately)... 140.00 Uniform and equipment expenses......78.00-100.00 TOTAL... $240.00 Travel/living expenses for clinical training are the personal responsibility of the student and will vary depending on the location of the clinical site. Students are NOT guaranteed local placements. Textbooks... 1,300.00 Background Check / Fingerprinting Fee... 85.00 Drug Screening (annually, $33.00 x 2)... 66.00 Orientation fees... 64.00 TOTAL... $1,515.00 ESTIMATED cost for the program - In-state...$9,062.50 Out-of-state... $28,373.54 * Fees are subject to change without notice. Page 18 of the 2014-2015 catalog PTA Estimated Expenses 6/2/2014

GULF COAST STATE COLLEGE - HEALTH SCIENCES DIVISION APPLICATION FOR PTA PROGRAM ADMISSION 5230 West U.S. Highway 98 Panama City, FL 32401-1058 (850) 872-3827 or 913-3311 Toll Free: 1-800-311-3685 Fax: (850) 747-3246 Answer ALL Questions: Please TYPE or PRINT (Please submit form as soon as possible) Name: Home Address: First Middle Last Maiden Name Street & Number City State Zip County GCSC Student ID #:- SS# Female Male Permanent or Mailing Address (If different from above): E-Mail: Home Phone: ( ) Business Phone: ( ) Cell Phone: ( ) EDUCATION OFFICIAL TRANSCRIPT(s) must be received by the Office of Admissions & Records. ALL schools and colleges, including High School transcript, attended must be listed for the application to be complete. Use additional sheets if necessary. Name of School High School or GED: Location of School From (Month/ Year) To (Month/ Year) Did you Receive Diploma, Degree, or Certificate? What was your Major / Minor? Vocational / Other Technical Program College or University: College or University: LICENSES AND CERTIFICATIONS Type Issued by Which State or Agency? License / Cert. Number Date Issued/Expired

CONTACT INFORMATION Please provide information about three people who will always know where to locate you: Name 1. 2. 3. Mailing Address Telephone Number HEALTH RELATED WORK EXPERIENCE and / or VOLUNTEER EXPERIENCE Use additional sheets if necessary 1. EMPLOYER: Address Phone: Extension Street & Number City State Supervisor s Name Title Dates employed: From To Nature of your Job Duties: Mo./Yr. Mo./Yr. Reason for Leaving Full-Time Part-Time 2. EMPLOYER: Address Phone: Extension Street & Number City State Supervisor s Name Title Dates employed: From To Nature of your Job Duties: Mo./Yr. Mo./Yr. Reason for Leaving Full-Time Part-Time PLEASE READ AND SIGN THE FOLLOWING I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I understand that any misrepresentation, omission or falsification of information is cause for denial of admission to the program. I understand that illegal use, possession, and/or misuse of drugs are reasons for immediate dismissal from any of the programs in the Health Sciences Division. I further understand that background checks and drug screening are routinely required at most clinical facilities prior to the students clinical placement. Signature of Applicant RETURN APPLICATION TO: Gulf Coast State College Health Sciences Division Room 200 5230 W. U.S. Highway 98 Panama City, FL 32401-1058 Date IN CASE OF EMERGENCY NOTIFY: Name: Address: Phone:

PTA TECHNICAL STANDARDS The practice of physical therapy is a physically demanding occupation. All applicants must, therefore, meet the following technical standards to be admitted into the Physical Therapist Assistant Program: 1. Able to tolerate being physically active the entire working day. 2. Able to lift 70 pounds as needed. 3. Able to transfer, lift and guard patients safely, providing appropriate assistance. 4. Able to bend, stoop, squat and lift numerous times daily. 8. Able to carry out fine motor and manual dexterity skills with tactile ability sufficient for physical assessment. 6. Mental acuity and judgment skills to adequately and safely perform job requirements. 7. Able to see and hear adequately in order to respond to auditory and visual cues for the observation, monitoring and assessment of patients. 8. No medical problems such as brittle diabetes, uncontrolled seizures, etc. which could endanger self or others if such should occur while providing patient care. 9. Critical thinking ability sufficient for sound clinical judgment. 10. Interpersonal abilities sufficient to interact with individuals, families, and groups from a variety of social, educational, cultural and intellectual backgrounds. 11. Communication abilities sufficient for interaction with others in both verbal and written form. I have read the above and feel that it is within my ability to carry out the duties, responsibilities and qualifications of a Physical Therapist Assistant. SIGNATURE DATE

GULF COAST STATE COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM PHYSICAL THERAPY EXPERIENCE FORM Extra points will be granted towards admission to those applicants who have documented greater than 40 hours of observation / volunteer or work experience in physical therapy. A Physical Therapist or Physical Therapist Assistant must verify the observation or work experience and this form must be submitted by the deadline. * We do not accept other PT experience forms, and this form may be duplicated if needed.* NAME: I. OBSERVATION / VOLUNTEER experience in a Physical Therapy Department. (Be specific in number of hours completed) Setting* Facility Name Date Hours PTA / PT Signature License # IP / OP Total Observation Hours on this page: IP: OP: Total: Total Observation Hours for all pages: If using multiple pages, please total hours on each page, then fill in this portion on the final page. IP total OP total Total *Note: Must have at least 10 hours in each setting to be eligible for additional points. IP = Inpatient setting (Hospital, Nursing Home, Rehabilitation Center, *patient sleeps in facility) OP = Outpatient setting (Everything else: outpatient clinic, pediatrics, home health)

GULF COAST STATE COLLEGE PHYSICAL THERAPIST ASSISTANT PROGRAM PHYSICAL THERAPY EXPERIENCE FORM * We do not accept other PT experience forms, and this form may be duplicated if needed.* NAME: II. WORK EXPERIENCE in Physical Therapy: Paid Employment in a Physical Therapy Department; work must include direct patient care. (Be specific in number of hours completed) Facility Name Setting* IP / OP Date Hours PTA / PT Signature License # Total Observation Hours for this page: IP: OP: Total: Total Hours of Work Experience: If using multiple pages, please total hours on each page, then fill in this portion on the final page. IP total OP total Total *Note: Must have at least 10 hours in each setting to be eligible for additional points. IP = Inpatient setting (Hospital, Nursing Home, Rehabilitation Center, *patient sleeps in facility) OP = Outpatient setting (Everything else: outpatient clinic, pediatrics, home health)